"Are you pregnant?" the young girl asked me suddenly. Horrified that she had discovered my secret before I'd even had the chance to tell my supervisor, I answered her with a therapeutic technique designed to keep the focus on the patient.
"Well, that's an interesting question," I commented, noting the five pairs of adolescent female eyes scrutinizing my torso. "What thoughts do you have about that?"
I'm a clinical psychologist specializing in the treatment of eating disorders; the girl and four others, each a member of my weekly eating-disorders therapy group, revealed their concerns about my being pregnant. How much would I have to eat? they wondered. Did I know whether I was having a girl or a boy? Which would I prefer? And, most provocative of all, if I had a girl, what would I do to ensure that she didn't develop an eating disorder?
About 1% of adolescent girls develop anorexia nervosa, and an additional 2% to 3% are diagnosed with bulimia nervosa, says the National Institute of Mental Health. One in 10 individuals with anorexia dies as a result of the illness. Complications from bulimia, such as vomiting-induced potassium losses that can lead to cardiac arrest, also may result in death, but the institute lacks numbers.
While most girls don't develop these severe eating disorders, many are preoccupied with their weight from an astonishingly young age. As early as first grade, children express dieting and weight concerns and even engage in eating-disordered behaviors, according to a 1996 study by psychologists Ellen Flannery-Schroeder of Temple University and Joan Chrisler of Connecticut College. By the eighth or ninth grade, one out of two girls has been on a diet at some point in her life, suggests research conducted at the University of Missouri.
Girls are about 10 times more prone to develop these disorders than are boys, said J. Kevin Thompson, professor of psychology at the University of South Florida and co-author of "Exacting Beauty: Theory, Assessment and Treatment of Body Image Disturbance" (American Psychological Assn., 1999). Why the discrepancy? Researchers point to the experience of adolescence, when girls' and boys' bodies undergo profound but dramatically different physical changes.
The transformation that girls experience--acquiring more fat and becoming more rounded--are condemned by America's weight-obsessed culture. In contrast, the increased muscularity that boys undergo is heralded.
"Culture collides with biology," Thompson said.
In an effort to control their developing bodies, girls may turn to dieting, a risk factor for developing an eating disorder in adolescence, according to a recent study at Stanford University. Adolescent girls in the study who dieted, who perceived greater social pressure to be thin and who were less happy with their bodies were also more likely to engage in eating-disordered behaviors such as bingeing and purging.
Just why some girls develop eating disorders and others do not is not known. Genetics appears to play a role in the development of anorexia, since the chances of both members of a pair of twins having it are higher if they are identical rather than fraternal. Researchers at Virginia Commonwealth University have reported similar findings for bulimia.
Culture also plays an important role, because eating disorders are virtually nonexistent in non-Westernized countries, and girls who immigrate to Westernized nations are more likely to develop an eating disorder than those who remain in their non-industrialized homeland.
The incidence of eating disorders rose dramatically in the 1960s, a time of great change in the roles of women, as historian Joan Jacobs Brumberg points out in her book, "Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease" (Harvard Press, 1988).
Brumberg notes that as increasing numbers of women began entering the work force and competing alongside men for the same jobs, health officials became aware that their daughters were exhibiting an increasing number of eating disorders. She and other theorists speculate that the demands to be successful professionally and to be attractive and acceptably feminine place women in a bind. The fashion industry, meanwhile, has promoted an increasingly waif-like beauty ideal.
At the same time, Ruth Striegel-Moore, professor of psychology at Wesleyan University, views the increase in disorders as a product of better epidemiological surveying and a greater awareness of such problems. Prior to the 1970s, rates of eating disorders were assessed by looking at the number of patients reporting to treatment centers, a method that may have grossly underestimated rates.
Certainly, American culture plays a significant role in helping children develop the attitudes that are the crux of many eating-disordered behaviors. But it explains only a piece of this puzzle since all girls are exposed to similar societal pressures to look attractive and be successful, and most do not develop eating disorders.
Beyond biology and culture, other variables that appear to be important are ethnicity and family environment. White adolescent females, for example, are almost twice as likely to view themselves as overweight than are black adolescent females, according to a 1997 study at the University of South Carolina School of Public Health. These white teenagers are nearly four times as likely to diet and exercise in an effort to manage their weight, and six times as likely to use diet pills and vomiting as means of losing weight.
The dynamics within one's family also play an important role in determining attitudes and behaviors toward weight and food. A 1997 University of Minnesota study suggests that girls with parents who make comments about their daughters' weight are more likely to be unhappy with themselves and go on diets.
Stefanie Gilbert practices with the Metropolitan Psychiatric Group in Bethesda, Md.